Welcome to the Pulse!

A 46 year old male presented to the emergency department complaining of headache and vomiting. He had no chest pain or shortness of breath. He was noted to be lethargic in the emergency department and was intubated.

The EKG shows a sinus rhythm at rate of 60 with diffuse T wave inversions in leads V3-V6, I, II, III and aVF. This can be a sign of inferolateral cardiac ischemia. However, in the context of this patient’s symptoms, it most likely is a sign of intracranial hemorrhage. The patient had a head CT which showed an extensive intraventricular hemorrhage. A ventriculostomy was placed and the patient was admitted to the ICU.

T wave inversions can be caused by increased intracranial pressure. This can occur in intracranial hemorrhage or ischemic stroke. The finding is classically described as widening and inversion of the T waves in the lateral leads. These are sometimes called cerebral T waves. You can also see a prolonged QT interval (not present on this EKG) and bradyarrhythmias (Marriott’s Practical Electrocardiography, 10th ed, Ch 11, p.219). The mechanism for this is unclear. These findings are usually transient.